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Discussion

Progress notes.

Hi allnurses community!

Im a new grad and have always found I struggle with writing notes.

Patients who have notable things happen during the day, I write as I go.

But for the other patients where I write near to the end of the shift I struggle with.

I find I over think it and my mind goes blank.

I am just wondering if anyone has any structure to writing progress notes? As a student I remember being given a really good one that I can't remember the whole thing. It was something like CNS, elimination etc.

I've heard of the "go from head to toe" but I'm not a fan..

Just something as a guide and to jolt the memory as I have so much running through my mind in one day.

Much appreciated! :)

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    Think in terms of systems. Divide things into Neuro, CV, GI, GU etc. Then further divide into before and after. For example: write what rhythm the patient was when you picked them up, so patient was in SR. After two hours they went into a stable A-Fib. MD notified. EKG done with no changes. Maintained adequate BP. Patient started on Amiodarone at xmg. Pt sponteneously went back into SR at 17:00pm. So you write the baseline, the intervention, the reassessment and the resolution. Another example: pt c/o pain 5/10. Was given 2mg Morphine at 14:00pm. Reassessed at 14:30pm and pain has resolved to a 1/10. Pt was repositioned and reports being more comfortable.

    If you use an EMR then document your assessment as determined by the system you use for any normal exam, and then write a narrative on any exception. So, perhaps you have to click a button for each system that is normal but the only thing that they had issues with was that they didn't pass urine for 5 hours. Document "normal" on everything but document the heck out of the urinary issue. Makes notes on a piece of paper in your pocket as you go so you remember things. Hope that helps.

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    What type of charting system are you using, and what are your employer-given requirements with regard to narrative notes?

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